AT THE Lord Mayor Treloar Hospital, Alton, England, in 1949, during an otoplasty procedure, Prof T. P. Kilner mentioned that the prominence of the auricular helix generally referred to as Darwin's tubercle was actually first described by Woolner. No references were given and no further action taken. Twenty years later, in 1969, at the University of Miami School of Medicine, during an otoplasty procedure where one of these tubercles required removal to achieve cosmetic symmetry with the opposite auricle, Darwin's priority was again questioned. On this occasion a search of the literature was instigated. Show
Research1 revealed that 100 years ago Darwin and Woolner lived in London and it is likely they met occasionally over a pint of bitters at the Garrick Club frequented by artists, authors, and actors. Thomas Woolner, a sculptor and poet and later destined to be a Professor of the Royal Academy, had become known for 21. A nurse performs an initial examination of a client brought to the emergency department aftersustaining a head injury in an automobile accident. Which characteristic of discharge from theears should alert the nurse that the client has a cerebrospinal fluid leak?22. The patient asks the nurse why the nurse put the tuning fork on the bone behind the ear. Which Get answer to your question and much more is the best response by the nurse? Get answer to your question and much more 23. A nurse is educating a client about the function of the parts of the auditory system. Which is thefunction of the eustachian tube?24. Which of the following describes a condition characterized by abnormal spongy bone formation Get answer to your question and much more around the stapes?25. A nurse examines the ear of a client diagnosed with an obstructed eustachian tube. What finding Get answer to your question and much more should the nurse anticipate upon assessment? Get answer to your question and much more 26. The results of a client's Rinne test are as follows: bone condcution > air conduction. Howshould the nurse explain these findings to the client?27. The nurse is planning to conduct the Weber test on an adult male client. To perform this test, the Get answer to your question and much more Get answer to your question and much more 28. The nurse has performed the Rinne test on an older adult client. After the test, the client reportsthat her bone conduction sound was heard longer than the air conduction sound. The nursedetermines that the client is most likely experiencing29. After examining the client’s tympanic membranes, the nurse documents “Right tympanic Get answer to your question and much more membrane, red and bulging with no light reflex.” The nurse recognizes that these are signs of Get answer to your question and much more 30. A nurse is preparing a community education session on hearing loss. Which information shouldthe nurse include? Get answer to your question and much more Darwin’s tubercle (DT) is a congenital outer ear deformity characterized by posterior thickening of the auricular helix. This trait may be unilateral or affect both ears but carries only vestigial significance. Nevertheless, unbeknownst to many surgeons, it is particularly common in certain ethnic
groups,1 namely 10% of Spaniards,2 40% of Indians,3 and 58% of Swedes.4
Additionally, it has been recognized as a possible cause for prominent ears.5 Though most individuals with DT are unaffected by it, some may complain about its psychological impact, warranting surgical correction.6 Traditionally, DT hypertrophy has been corrected by remodeling the
cartilage excess through surgical resection and placement of sutures.7 Though effective, this aggressive approach may cause skin necrosis and pathologic scarring, and surgery may even leave residual cartilage defects if performed unattentively.8 Recently, cartilage reshaping has been
achieved with laser irradiation and radiofrequency heating, without cutting, suturing, or visible scars.9–11 However, these approaches require expensive instrumentation and can cause burns, infections, and
scars.12 All these techniques are effective tools but carry downsides, which could potentially be overcome by using a different approach. The aim of this case report is to describe a noninvasive aesthetic medicine procedure based on plasma exeresis, that can be safely implemented to correct hypertrophic DTs. A standardized
approach was implemented, with 60-day intervals between treatments. Written informed consent was obtained from the patient whose case is portrayed in this study. After each session, pain intensity was assessed using a visual analog scale,13 a standard unidimensional method used to measure patient’s recording of pain progression. Patient satisfaction was recorded using the Global Aesthetic
Improvement Scale (GAIS),14 which has been validated for the assessment of response to treatment in aesthetic medicine. A 28-year-old female patient with Fitzpatrick skin phototype III complained of her right ear’s appearance, due to DT hypertrophy, which caused psychological distress. DT had a 3-mm diameter. Before beginning the treatment, a galenic formulation of local
anesthetic creams (lidocaine 20%, procaine 5%, and tetracaine 5%) was topically applied on the surface of the auricle, letting it sit for 15–20 minutes.15 The treatment was conducted using the PLEXR Plus device (GMV S.r.l., Rome, Italy), which delivers a microplasma ray heating the treated surface. The medium power handheld device (output of 11 Vcc) was selected for this patient. Treatment
was applied with each spot delivered 1 mm away from the next. The patient was instructed to sleep supine or with her head lying on the unaffected side, to cleanse the treated area with lukewarm water daily, and to apply Neoviderm emulsion cream (Istituto Ganassini S.p.A., Milano, Italy) to reduce swelling and redness after treatment. No ear manipulation was recommended, but Sinema supplement (Judìfarm S.r.l., Naples, Italy) was prescribed to help reduce the swelling in the first 30 days. We
recommended SPF 50 sunscreen twice a day over the treated area for protection from potential sun damage until the skin fully healed. She underwent three treatments that lasted 5 minutes each, with 60-day intervals between sessions. Pain level during treatment was a 2 out of 10. Follow-up was uneventful, and at 6 months from the last session, we asked the patient to express her satisfaction with the result, which was “very much improved” on the GAIS
(Fig. 1). Clinical presentation of a 28-year-old patient with hypertrophic Darwin’s tubercle: (A) at two months and (B) at 6 months from initial treatment (C) using PLEXR plasma exeresis device. Voltaic arc dermabrasion (or plasma exeresis) consists in using the differences in voltage in the
device-skin interface to ionize gases in the space between the instrument’s tip and treated tissues. This generates a small electrical arc, which sublimates fluids contained in superficial tissues, forming a plasma, which causes controlled thermal damage used for skin resurfacing and rejuvenation.16 The thermal effect causes excess cartilage to progressively flatten and shrink. This effect
is distributed on the superficial-most structures, without unwanted heat transmission to the adjacent tissues, therefore averting the risk of ear cartilage necrosis and/or frailty. The principle behind plasma exeresis is considerably different from other minimally-invasive technologies: conventional lasers can be diffracted, absorbed, or scattered,17 increasing the potential risk of
permanently damaging surrounding areas when improperly used.18 Plasma exeresis is also different from other devices such as Renuvion/J-Plasma (Apyx Medical, Clearwater, Fla.), which uses radiofrequency energy and helium to generate plasma.19 Renuvion/J-Plasma has been
cleared by the Food and Drug Administration for cutting, coagulation, and ablation of soft tissue during open and laparoscopic surgical procedures, but not for any aesthetic skin procedure. This is particularly relevant because their improper use has been associated with potentially life-threatening adverse events, including second/third-degree burns, infections, and bleeding.20 PLEXR devices have been successfully used for several noninvasive procedures, including nonsurgical blepharoplasty, treatment of rhytids, scars, acne, and benign skin lesions.16,21 The advantage is that patients
leave without incisions or sutures, with fast delivery of treatments and low morbidity. The controlled damage affects superficial-most soft tissues and usually heals within 10–15 days. However, cartilage reshaping is not immediate and occurs progressively over the following weeks. Although we reported no complications, treatments with PLEXR can still present adverse events, including skin retraction, scarring, and pigmentation (postinflammatory hyperpigmentation or hypochromia), which are rare
occurrences, though more common in nonwhite ethnicities.22 Scarring is a setback for which the treatment is contraindicated in patients with a propensity for keloids and hypertrophic scars. This is the first report of PLEXR being used for minor nonsurgical ear cartilage reshaping. Although the result is encouraging, PLEXR’s cartilage reshaping properties are limited: it causes superficial
tissue retraction but cannot remodel thicker ear cartilage, where the heat would not reach all the way through. In fact, plasma exeresis would be ineffective if used for nonsurgical otoplasties, unlike other technologies, which have already been described for that purpose. In fact, 1540 nm Er/Glass laser has been used to correct prominent ears,23 though it requires costly equipment and can
be associated with beam hazards or other side effects,24 which is why new technological innovations must be explored. We believe that plasma exeresis is an interesting tool for the correction of hypertrophic DT, with the potential of delivering fast treatments while keeping morbidity low. 1. Loh TY, Cohen PR. Darwin’s tubercle: review of a unique congenital anomaly. Dermatol Ther (Heidelb). 2016;6:143–149. 2. Ruiz A. An anthropometric study of the ear in an adult population. Int J Anthropol. 1986;1:135–143. 3. Singh P, Purkait R. Observations of external ear—an Indian study. Homo. 2009;60:461–472. 4. Hildén
K. Studien über das Vorkommen der darwinschen Ohrspitze in der Bevölkerung Finnlands. Fennia. 1929;52:3–39. 5. Ali K, Meaike JD, Maricevich RS, et al. The protruding ear: cosmetic and reconstruction. Semin Plast Surg. 2017;31:152–160. 6. Jones ES, Gibson JAG, Dobbs TD, et al. The psychological, social and educational impact of prominent ears: a systematic review. J Plast Reconstr Aesthet Surg. 2020;73:2111–2120.
7. Williams CH, Sternard BT. Complex ear lacerations. [Updated 2022 May 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. Available at https://www.ncbi.nlm.nih.gov/books/NBK525973/. 8. Stewart KJ, Lancerotto L. Surgical otoplasty: an evidence-based approach to prominent ears correction. Facial Plast Surg Clin North Am. 2018;26:9–18. 9. Sobol EN, Bagratashvili VN, Sviridov AP, et al. Phenomenon of cartilage shaping using moderate heating and its applications in otorhinolaryngology. Proc. SPIE 2623, Medical Applications of Lasers III; 1996. 10. Sobol E, Sviridov A, Omel’chenko A, et al. Laser reshaping of cartilage. Biotechnol Genet Eng Rev. 2000;17:553–578. 11. Keefe MW, Rasouli A, Telenkov SA, et al. Radiofrequency cartilage reshaping: efficacy, biophysical measurements, and tissue viability. Arch Facial Plast Surg. 2003;5:46–52. 12. Prohaska J, Hohman MH. Laser complications. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. Available at https://www.ncbi.nlm.nih.gov/books/NBK532248/. 13. Delgado DA, Lambert BS, Boutris N, et al. Validation of digital visual analog scale pain scoring with a traditional paper-based visual analog scale in adults. J Am Acad Orthop Surg Glob Res Rev. 2018;2:e088. 14. Callan P, Goodman GJ, Carlisle I, et al. Efficacy and safety of a hyaluronic acid filler in subjects treated for correction of midface volume deficiency: a 24 month study. Clin Cosmet Investig Dermatol. 2013;6:81–89. 15. Manojlovikj TD, Trombeva D, Pavlovska M. Stability investigations of galenic preparation-sterile multidose lidocaine HCl 2% anaesthetic gel. Eur J Hosp Pharm. 2012;19:153–154. 16. Rossi E, Farnetani F, Trakatelli M, et al. Clinical and confocal microscopy study of plasma exeresis for nonsurgical blepharoplasty of the upper eyelid: a pilot study. Dermatol Surg. 2018;44:283–290. 17. Ruiz-Esparza J. Nonablative radiofrequency for facial and neck rejuvenation. A faster, safer, and less painful procedure based on concentrating the heat in key areas: the ThermaLift concept. J Cosmet Dermatol. 2006;5:68–75. 18. Sotiris TG, Dimitris V, Nikolaos G. Clinical and histological presentation after plexr application, needle shaping (Vibrance) and O.F.F. Pinnacle Med Med. 2015;2:522–530. 19. Belenky I, Margulis A, Elman M, et al. Exploring channeling optimized radiofrequency energy: a review of radiofrequency history and applications in esthetic fields. Adv Ther. 2012;29:249–266. 20. U.S. Food and Drug Administration (FDA). 2022. FDA warns against use of renuvion/j-plasma device for skin procedures [online]. Available at https://www.fda.gov/medical-devices/safety-communications/fda-warns-against-use-renuvionj-plasma-device-certain-aesthetic-procedures-fda-safety-communication. [Accessed 23 May 2022]. 21. Sotiris TG, Nittari G, Sagaro GG, et al. A descriptive study on the applications of plasma exeresis in dermatology. J Clin Aesthet Dermatol. 2021;14:E58–E62. 22. Callender VD, Alexis AF, Daniels SR, et al. Racial differences in clinical characteristics, perceptions and behaviors, and psychosocial impact of adult female acne. J Clin Aesthet Dermatol. 2014;7:19–31. 23. Leclère FM, Trelles M, Mordon SR. Cartilage reshaping for protruding ears: a prospective long term follow-up of 32 procedures. Lasers Surg Med. 2011;43:875–880. 24. Smalley PJ. Laser safety: risks, hazards, and control measures. Laser Ther. 2011;20:95–106. What does it mean if you have a point on your ear?An ear normally develops with two folds of cartilage. With a Stahl's ear, a third fold of cartilage is present. If the upper portion of the ear (helix) unfurls, the result is a pointed ear. There are no physical symptoms associated with elf ear.
Which condition is characterized by the formation of abnormal spongy bone around the stapes?Otosclerosis, also called otospongiosis, is an abnormal bone remodeling in the middle ear in which a normal dense endochondral layer of bony otic capsule in the bony labyrinth is replaced by one or more foci of irregularly laid spongy bone and most commonly involves the stapes region.
Which characteristic of discharge from the ears should alert the nurse that the client has a cerebrospinal fluid leak?The chief presenting symptom one would expect when a CSF leakage through the ear is present is a clear, watery drainage from the ear.
Which terms refers to the progressive hearing loss associated with aging?Presbycusis, or age-related hearing loss, comes on gradually as a person gets older. It seems to run in families and may occur because of changes in the inner ear and auditory nerve.
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